Real-world outcomes of diffuse large B-cell lymphoma in the biosimilar era

Background

Diffuse large B-cell lymphoma (DLBCL) is an aggressive and the most common type of non-Hodgkin lymphoma (NHL). The clinical use of rituximab has improved the treatment response and survival of patients with DLBCL. The introduction of rituximab biosimilar into healthcare system has helped in providing a cost-effective treatment to B-cell lymphoid malignancies as standard of care and has improved access to patients worldwide. The aim of this study was to observe the real-world effectiveness and safety of Reditux™ and Ristova® in DLBCL patients.

Methods

Observational study in adults with DLBCL receiving Reditux™ or Ristova® across 29 centers in India (2015-2022). Effectiveness and safety were assessed up to 2 years after first dose.

Results

Out of 1,365 patients considered for analysis, 1,250 (91.6%) were treated with Reditux™ and 115 (8.42%) with Ristova®. At 2 years, progression-free survival (PFS) 69% [hazard ratio (HR), 1.16; 95% CI, 0.80-1.67], overall survival (OS) 78.7% (HR, 1.20; 95% CI, 0.78-1.86), response rates, quality of life (QoL), and overall safety in both the cohorts were comparable. The best overall response rate (BORR) at 6 months was comparable with no statistically significant differences between the Reditux™ and the Ristova® cohorts (89.2% vs. 94.3%). In multivariate analysis, BCL-2 and VAS were significant prognostic factors for PFS.

Conclusion

Reditux™ and Ristova® were comparable in real-world setting.

Clinical Trial Registration

ISRCTN registry, identifier (ISRCTN13301166).

Development of statistics as a discipline for clinical research: Past, present and future

This article traces the history and evolution of statistics in the era of evidence based medicine, and focuses on the Indian perspective of this growth of statistics as a discipline for clinical research. Statistics will assume a more inter disciplinary form. Use of software other than SAS likely to grow further. In India, innovative statistical methods will help propel the development of biosimilars. The future is exciting with statistics being used for real world evidence, development of biosimilars, mining of adverse event data and becoming a core function in medicinal product development and lifecycle maintenance.

A double-blind, randomized study of azithromycin compared to chloroquine for the treatment of Plasmodium vivax malaria in India

Azithromycin has demonstrated activity in a prevention of Plasmodium vivax infection, but no controlled treatment studies have been performed. We conducted a double-blinded trial in P. vivax malaria in which patients were randomized to either azithromycin 1,000 mg q.d. x 3 or chloroquine 600 mg q.d. x 2 then 300 mg on Day 3 followed by primaquine on Days 7 through 20. Eighty-five of 97 (88%) of those on azithromycin and 101 of 102 (99%) of those on chloroquine [difference 11%; 95% CI: -18, -4] were clinically cured at Day 7. The Day 28 results were similar [89% versus 99%, azithromycin versus chloroquine, respectively]. Parasitologic success was seen in 81 of 97 (84%) on azithromycin and 100 of 102 (98%) on chloroquine [difference 14%; 95% CI: -22, -6]. The median parasite clearance time was 55 hours on azithromycin and 20 hours on chloroquine (P < 0.001). Drug-related adverse events were seen in 13 of 98 (13%) on azithromycin and 24 of 102 (24%) on chloroquine (P = 0.062). Resolution of parasitemia was significantly faster with chloroquine compared with azithromycin, but azithromycin was better tolerated. These data provide support for further study of azithromycin to better define its role in the treatment of P. vivax malaria, either alone as second-line treatment or in combination with other active therapies.

A Multicenter Study of Azithromycin, Alone and in Combination with Chloroquine, for the Treatment of Acute UncomplicatedPlasmodium falciparumMalaria in India

BACKGROUND

Azithromycin has demonstrated in vitro and in vivo activity against Plasmodium falciparum, but small treatment studies have given mixed results.

METHODS

Participants with fever and with both a blood smear and a rapid diagnostic test positive for falciparum malaria were randomly assigned to groups that were treated with either azithromycin or chloroquine or to matched groups receiving a placebo. After an interim analysis, open-label combination therapy with both drugs was initiated.

RESULTS

At day 28, 5 (33%) of 15 participants in the azithromycin-treated group had remained free of fever, compared with 4 (27%) of 15 in the chloroquine-treated group. All subsequently enrolled participants then received combination therapy with azithromycin and chloroquine. In 61 (97%) of 67 participants, resolution of fever and parasitemia had occurred by day 7, and, through day 28, no clinical or parasitologic relapse had occurred in them.

CONCLUSIONS

Resolution of parasitemia was inadequate with monotherapy with either azithromycin or chloroquine, but combination therapy provided substantially improved clinical and parasitologic outcomes. The combination of azithromycin and chloroquine may be an effective alternative treatment for falciparum malaria and deserves further study.

Case-control study of non-Hodgkin's lymphoma among women and heterosexual men in the San Francisco Bay Area, California

A population-based case-control study was conducted between 1988 and 1995 in the San Francisco Bay Area of California to determine risk factors for non-Hodgkin's lymphoma. Participants completed in-person interviews, and blood was drawn to test for viruses and lymphocyte subsets. This report includes data for 1,281 cases and 2,095 controls. In multivariate analyses, the factors associated with a decreased risk for non-Hodgkin's lymphoma were allergy to plants, bee and wasp stings, five or more vaccinations, drugs to lower blood cholesterol, nonsteroidal anti-inflammatory drugs, total number of sexual partners, and lifetime marijuana use, whereas an increased risk was associated with cimetidine and other histamine H2-receptor antagonists, splenectomy, gonorrhea, and body mass index. Unique to sex-specific models was an increased risk for endocrine gland disorders among women and for polio among men. Median CD3, CD4, CD8, CD20, and lymphocyte counts for non-Hodgkin's lymphoma patients were significantly lower than those for controls. These results implicate environmental factors that may influence the early stages of lymphomagenesis by stimulating the immune system. Antigen-driven B cells that accumulate to form lymphoma may be suppressed by immunologic stresses such as exposure to an increased number of sexual partners and to certain medications. A history of allergies provides evidence for a persistent capacity for B-cell differentiation and therefore a decreased accumulation of B cells. The decreased risk for non-Hodgkin's lymphoma with use of nonsteroidal anti-inflammatory drugs and cholesterol-lowering drugs is consistent with a macrophage inflammatory role in B-cell proliferation.

A population based, case control study of non-Hodgkin's lymphoma in patients with rheumatoid arthritis

OBJECTIVE

Epstein-Barr virus (EBV) associated lymphoproliferative disorders (LPD) similar to those that occur in immunosuppressed solid organ recipients have been reported in patients with rheumatoid arthritis (RA). These LPD cause significant morbidity and/or mortality in a state of sustained immunosuppression, but may spontaneously regress if immunocompetence is restored. We determined the population based frequency of EBV associated LPD relative to all non-Hodgkin's lymphomas (NHL) that occur in the general population of patients with RA.

METHODS

Forty-two case patients with NHL and RA and 49 control patients with NHL and no RA were identified in a population based, case control study of NHL that occurred in a 6 county Northern California area during the years 1988-94. The lymphoma tissue specimens were reviewed and the diagnosis of NHL was confirmed. In addition, the specimens were analyzed for NHL grade, histologic subtype, histopathologic features associated with immunosuppression, immunophenotype, and the presence of EBV genome in the tumor cells.

RESULTS

No significant differences were identified between NHL in the RA case group and the control group (no RA) with respect to any variables investigated. One patient (2%) in the case group and one (2%) in the control group developed LPD containing EBV.

CONCLUSION

Our findings reveal that EBV associated lymphomas represent only a small fraction of all NHL in the general RA patient population. EBV associated LPD should be recognized when they occur because they require a special approach to patient management. However, these data indicate that the majority of NHL that occurs in patients with RA is probably coincidental with RA and not the result of significant immunosuppression.

Hair-color products and risk for non-Hodgkin's lymphoma: a population-based study in the San Francisco bay area

OBJECTIVES

As part of a large, epidemiologic study of non-Hodgkin's lymphoma, this study investigated a possible association between use of hair-color products and non-Hodgkin's lymphoma.

METHODS

A population-based case-control study was conducted in the San Francisco Bay area. Of 4108 participants, 2544 were questioned about use of hair-color products. Control subjects were identified by use of random-digit dialing.

RESULTS

Ever use of hair-color products was reported by 56% of case and 56% of control women and 10% of case and 9% of control men. Risks were not elevated for women for use of any hair-color products. Men who ever used semipermanent hair color had slightly elevated risks for non-Hodgkin's lymphoma, with trends associated with greater lifetime frequency of use and frequency of use per year, although individual confidence intervals overlapped unity. These elevated risks were diminished with exclusive use of semipermanent products, and confidence intervals overlapped unity.

CONCLUSIONS

Integration of our results with those from experimental animal studies and other epidemiologic studies provides little convincing evidence linking non-Hodgkin's lymphoma with normal use of hair-color products in humans.

Different disease rates in two populations: how much is due to differences in risk factors?

Two populations with different disease rates may differ in their risk factors for the disease. If so, it is desirable to know what proportion of the disease excess in the high-risk population is attributable to its greater exposure to the risk factors. This proportion has been called the relative attributable risk (RAR). A related measure is the adjusted relative risk (ARR), defined as the ratio of rates in high-risk to low-risk populations that would be observed if the distribution of risk factors in the high-risk population equalled that of the low-risk population. We present methods for obtaining consistent estimates and asymptotic confidence intervals for both the RAR and the ARR using data from case-control studies in the two populations. The methods are applied to the problem of estimating the differences in ovarian cancer incidence between U.S. white women (high-risk) and U.S. black women (low-risk) attributable to differences in reproductive risk factors. Simulations show that the methods perform well; however, when the true RAR is close to 0 or 1 or when sample sizes are small, RAR estimates may fall outside the unit interval. We discuss circumstances when the true RAR lies outside the unit interval; in such circumstances the ARR is easier to interpret.

Non-Hodgkin's lymphoma in homosexual men in the San Francisco Bay Area: occupational, chemical, and environmental exposures

Chemical, occupational, and other exposures as risk factors for non-Hodgkin's lymphoma (NHL) among homosexual men are reported from a population-based case-control study of 1593 eligible subjects with NHL and 2515 control subjects conducted in the San Francisco Bay Area between 1988 and 1995. Results are presented for 312 homosexual men with NHL and 420 homosexual control subjects. HIV-positive patients were less likely than control subjects to have worked in technical, sales, and administrative occupations; service occupations; and precision production, craft, or repair-related occupations. They were likely to have had less exposure to petroleum products, aldehydes, cleaning solvents, adhesives, insecticides, welding fumes, and tar, pitch, soot, or ash. The HIV-negative patients were less likely than the control subjects to have worked in managerial or professional specialty occupations and in technical, sales, or administrative occupations. HIV-negative patients were somewhat more likely than control subjects to have been exposed to herbicides (OR = 2.0, CI = 0.89 to 4.7), to radioactivity (OR = 4.7, CI = 1.7 to 13), and to tar, soot, pitch, or ash (250+ hours: OR = 2.3, CI = 0.96 to 5.6). HIV-negative NHL patients also were somewhat more likely to have lived on a farm as children than the control subjects (OR = 2.4, CI = 1.0 to 5.6). Pooled over HIV status, patients were somewhat more likely to have worked as motor vehicle or rail operators for more than 1 year (OR = 2.1, CI = 0.98 to 4.4). Most occupational exposures were of brief duration and many chemical exposures were reported as minimal. No clear and strong associations were found, although the risk for NHL related to exposure to several chemicals generally was reduced among HIV-positive men and elevated among HIV-negative men.

Non-Hodgkin's lymphoma in HIV-positive and HIV-negative homosexual men in the San Francisco Bay Area: allergies, prior medication use, and sexual practices

Lifestyle, sexual history, and medical history characteristics were analyzed as risk factors for non-Hodgkin's lymphoma (NHL) in a population-based case-control study of 1593 subjects with NHL and 2515 control subjects conducted in the San Francisco Bay Area between 1988 and 1995. The results for homosexual men, 312 with NHL and 420 control subjects, showed that HIV infection was associated with a 20-fold increased risk for NHL. Among HIV-positive homosexual men, after adjustment for other factors, those that were associated with a reduced risk for NHL were frequency of receptive anal intercourse between the ages of 20 and 29 (1 to 9 times: OR = 0.63; > or = 10 times: OR = 0.37; trend: p = 0.02), allergy to grass, hay, leaves, plants and pollen (OR = 0.35, CI = 0.19 to 0.64), number of bee or wasp stings (1 to 3 times: OR = 0.65; > or =4 times: OR = 0.56; trend: p = 0.07), use of Tagamet (cimetidine) for 4 consecutive weeks or longer (OR = 0.39, CI = 0.17 to 0.89), vaccination against influenza (OR = 0.41, CI = 0.23 to 0.74), and lifetime frequency of amphetamine use (1 to 19 times: OR = 0.59; > or =20 times: OR = 0.38; trend: p = 0.003). Among HIV-negative homosexual men, after adjustment for other factors, factors that were associated with NHL status were frequency of receptive anal intercourse between the ages of 20 and 29 (1 to 9 times: OR = 0.39; > or =10 times: OR = 0.20; trend: p = 0.001), nonmedication allergies (OR = 0.43, CI = 0.21 to 0.89), vaccination against poliomyelitis at <10 years (OR = 0.41, CI = 0.17 to 0.99), and having five or more siblings (OR = 3.6, CI = 1.7 to 7.7). An increased immunosuppressive effect of seminal fluid on sensitive rectal tissue and support from earlier work suggesting that HIV-related lymphomas may be outgrowths of antigen-driven B cells provide a possible mechanism for the results of this study. The role of allergic reactions in NHL is likely to be complex and may be related to B-cell differentiation. These associations may provide insight into an antigen-driven process early in lymphomagenesis.

Patient outcomes after spinal reconstructive surgery in patients > or = 40 years of age

This study provides outcome data on the quality of life in 84 patients 40 years of age or older who had spinal reconstructive surgery. A 30-min questionnaire covering the patients' pre- and postoperative functional status, expectations for surgery, medication use, quality of life, and overall satisfaction was administered via telephone by a trained interviewer. Clinical data were obtained from chart and radiographic review. The majority of the patients had back or leg pain as their indication for surgery. Diagnoses included kyphosis, scoliosis, spinal stenosis, spondylolisthesis, and failed surgery. Overall satisfaction with functional status and surgical outcome was 81%, and there was significant improvement in most functional measures. This study suggests that improved qualify of life for the majority of appropriately selected spinal reconstruction patients is achievable in this mature population.

Prostate-specific antigen as predictor of prostate cancer in black men and white men

BACKGROUND

The increasing incidence of prostate cancer creates complex issues in health care management and cost containment. There is a need to evaluate serial measurements of prostate-specific antigen (PSA) as a marker for long-term risk of clinically important prostate cancer (stages B through D).

PURPOSE

We used a nested case-control design within a retrospective cohort study to evaluate serial PSA concentrations in relation to subsequent prostate cancer diagnoses.

METHODS

Participants included 40 black and 96 white men with subsequent diagnoses of prostate cancer and 84 black and 100 white men without such diagnoses (control subjects) in a multiphasic health screening program conducted by the Kaiser Permanente Medical Care Program of Northern California. Serial serum samples were collected 1.5-23 years before prostate cancer diagnosis.

RESULTS

Median serum PSA concentrations, specific for age and subsequent cancer status, were similar in blacks and whites. Concentrations in control subjects increased exponentially with age, with a doubling time of 24.9 years. Concentrations in men with stage A cancer were similar to those in control subjects. Until about 13 years before diagnosis, PSA in men with subsequent cancer stages B through D increased exponentially with age, with a doubling time similar to that of control subjects. Thereafter, the PSA concentrations increased exponentially, with a doubling time of 4.3 years. Rapid increase in PSA concentration started about 1.5 years earlier for men with stage D cancer than for men with stage B or C cancer. The single PSA measurement drawn closest to diagnosis was a more sensitive marker of stages B through D cancer within the next 7 years than was any index of change that also took account of earlier PSA readings.

CONCLUSIONS

These data suggest that 1) age-specific PSA concentrations are similar in black men and white men and 2) current PSA concentration, specific for age, outperforms changes in past concentrations in identifying the man who will develop stage B, C, or D cancer within 7 years, albeit at the cost of a slightly higher rate of false-positive results. This interpretation needs confirmation in other data containing many serial PSA measurements within a few years of diagnosis.

Comparison of control subjects recruited by random digit dialing and area survey

Although random digit dialing (RDD) is an accepted and commonly used method of sampling populations for controls in case-control studies, there have been surprisingly few attempts to compare the accuracy of RDD with that of the best traditional alternative, i.e., household area surveys. The aim of the present study was to compare a variety of characteristics of control subjects selected by RDD and area survey methods. All data were gathered through in-person interviews of both types of control subjects. The area survey identified a population-based sample of 20- to 79-year-old residents of two Washington State counties in 1978 and 1979. Control groups for three case-control studies of bladder cancer, gynecologic cancers, and multiple myeloma were drawn from this area sample, for a total of 240 control subjects. Controls aged 21-64 years from the same counties were identified for the National Bladder Cancer Study using RDD telephone sampling during the same time period. There were 134 respondents in the RDD control group. Overall, the two control groups selected by these two different methods yielded similar estimated frequencies of various population characteristics. The small differences observed in some age/sex subgroups and the statistical significance of the overall measure of association for occupational exposure to organic substances may be attributed to multiple comparisons.